- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,698.24 / $1,698.24 / $1,698.24
| Facility | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $1,096.48 / $1,698.24
| Professional | | $831.76 | $1,096.48 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,621.81 / $1,621.81 / $1,949.84
| Facility | | $1,621.81 | $1,621.81 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,479.11 / $1,479.11 / $1,479.11
| Professional | | $1,479.11 | $1,479.11 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $1,202.26 / $1,202.26
| Facility | | $870.96 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $891.25 / $1,380.38
| Professional | | $891.25 | $891.25 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $977.24 / $1,148.15
| Professional | | $891.25 | $977.24 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $1,698.24 / $2,691.53
| Facility | | $741.31 | $1,698.24 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $851.14 / $1,584.89
| Facility | | $645.65 | $851.14 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $954.99 / $1,380.38
| Professional | | $707.95 | $954.99 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $9,332.54 / $9,332.54 / $9,332.54
| Facility | | $9,332.54 | $9,332.54 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $13,803.84 / $13,803.84 / $13,803.84
| Professional | | $13,803.84 | $13,803.84 | $13,803.84 |